Articles Tagged withattorney for health care fraud

Those who are under investigation for health care fraud may face years in federal prison if they are found guilty, or they ay face civil charges that result in much less severe penalties. It is up to the discretion of the federal prosecutor to determine if the case will be criminal or civil. If you have come forward to report health care fraud, how do you know whether those you have turned in will face criminal or civil charges?

Types of Health Care Fraud

It can be helpful to understand some of the basic laws surrounding health care fraud. The following are come key laws that, when violated, can be result in serious consequences:

Even though the Anti-Kickback Statute is a federal criminal statute that results in serious penalties when violated, it is also one that physicians and healthcare professionals violate on a regular basis. If you believe you were referred to a physician or other healthcare provider as part of a monetary or other valuable exchange, you may have witnessed an Anti-Kickback Law violation. However, there are certain “safe harbors” that protect physician payment plans that would otherwise constitute a violation under the Anti-Kickback Statute. If you are unsure whether your physician’s payment plan falls into one of the safe harbors, contact the attorneys at Willoughby Brod to get your questions answered.

What is the Anti-Kickback Law?

The Anti-Kickback Statute says that physicians and hospitals are not permitted to refer patients to other healthcare providers in exchange for something of value, whether that is cash or something else. The purpose of this statute is to ensure that referrals are genuine and based on merit rather than based on familial or professional networks.

It is illegal in California to commit health care fraud, yet with the confusing payment bureaucracy for health care in the United States, health care fraud occurs more frequently than most people think. Health care fraud, also known as medical insurance billing fraud, health insurance fraud, Medicare fraud, Medi-Cal fraud, or HMO fraud, takes the form of many different types of improper and illegal actions. By familiarizing yourself with the most common types of health care fraud schemes, you may be able to identify if and when your health care provider is committing health care fraud. If you have information regarding improper billing or other types of health care fraud from your health care provider, call Brod Law Firm at (800) 427-7020 today to speak with an experienced health care fraud attorney and learn more about your rights and remedies today.

The False Claims Act (FCA), which prohibits entities that conduct business with the government from defrauding the government, goes all the way back to the time of the Civil War. It is sometimes called the Lincoln Law because of the president who was in office when the law went into effect.

Since the advent of Medicare and Medicaid, physicians and hospitals fraudulently obtaining payments from publicly funded healthcare programs have been defendants in many FCA lawsuits. Often the violation is not as simple as doctors submitting claims to Medicare for services they did not perform, although such fraudulent claims certainly do constitute FCA violations. Likewise, some FCA violations occur when doctors perform unnecessary procedures (for example, performing a surgery when the patient’s condition could be adequately managed with medication) just to be able to bill Medicare for them. It can even be an FCA violation if a doctor benefits financially from referring a Medicare or Medicaid patient for other services. If you are a healthcare worker and have evidence that your workplace has intentionally benefited financially from referrals made at the expense of Medicare or Medicaid, filing aqui tam lawsuit could offer you legal and financial protection while also protecting patients and taxpayers from fraud.

California lawmakers are concerned with health care providers who may be taking advantage of patients by unnecessarily enrolling them into commercial health care plans in order tomaximize the provider’s reimbursement rates. Lawmakers believe some providers are encouraging sick individuals to enroll in commercial health care plans, which the providers then pay the premiums for in addition to providing the patient medical services. The providers financially benefit from the patients utilizing these health plans by receiving reimbursements for their services.

While providers claim their third-party premium payments are intended to help people get the medical care they need, lawmakers are concerned it is a way for providers to get greater reimbursements than the individual’s Medicare or Medicaid coverage would provide. While the scheme may not rise to the level of health care fraud, legislators worry that it takes advantage of the system and patients.

Lawmakers also worry about the providers ceasing premium payments. Many providers choose to end payments at a certain point, causing sick patients to lose their coverage. A recently introduced bill would create safeguards against such occurrences.

The U.S. Department of Justice (DOJ) announced mid-March that a dentist based in Los Angeles has been charged with conducting anidentity theft and health care fraud scheme. Benjamin Rosenberg, D.D.S., 58, faces six counts of health care fraud and two counts of aggravated identity theft. According to the unsealed court documents, Rosenberg allegedly billed a number of insurance companies for dental procedures he never actually provided. Rosenberg would bill insurance companies using patients’ personal identification information without their consent. One of the insurer’s Rosenberg allegedly defrauded was Denti-Cal, a Medicaid-funded dental program.

Are you aware of a dental fraud scheme? Call a San Francisco health care fraud lawyer at Brod Law Firm to discuss your situation and possible legal options.

In February, Julian Omidi, 49, a former physician, and Dr. Mirali Zarrabi, 55, were charged withmultiple counts of fraud in regard to a scheme surrounding their business, 1-800-GET-THIN. Two corporations, partly controlled by Omidi, were also named in the 37-count federal indictment, Surgery Center Management, LLC (SCM) and Independent Medical Services, Inc. (IMS).

Fraudulent Scheme Against Insurers

Omidi and Zarrabi promoted lap-band weight loss surgeries. Omidi created a process requiring prospective Lap-band patients to have at least one sleep study before the procedure could occur. Employees of SCM and IMS were incentivized with commissions to ensure sleep studies occurred.

In January 2018, the California Division of Workers’ Compensation (DWC) suspended 18 medical providers. These providers, many of whom are physicians, can no longer work in the state’s workers’ compensation system due to the loss of their medical license, criminal conduct, or fraud.

DWC Require to Suspend Certain Providers

AB 1244 went into effect January 1, 2017. This law requires the DWC to suspend any doctor or other medical provider from participating in the workers’ compensation system if:

Jimmy and Ashley Collins, a married couple from Tennessee, have been charged with operating ahealth care fraud scheme that unlawfully caused TRICARE to reimburse more than $65 million in funds. TRICARE is the federal health care program for U.S. military members, veterans, and their dependents. The Collins conspired with CFK, Inc., the owner of The Medicine Shoppe based in Utah, to submit false claims for compound medications that would be mailed to active duty marines and sailors in southern California.

Health Care Fraud Scheme

According to the government’s indictment, the Collins worked with numerousrecruiters within the Marines to try and induce TRICARE beneficiaries to obtain compound medications. Compound medications are specialty drugs mixed by a pharmacist when a patient has a specific medical need. These are not approved by the U.S. Food and Drug Administration, but they are obtained through prescriptions. Compound medications are used when an FDA-approved drug is not effective for a patient for a specific reasons, such as a patient needing a specialized dose.

Kmart Corporation, a subsidiary of Sears Holding Corporation, willpay the federal government $32.3 million to settle allegations of violations of the False Claims Act. A whistleblower alleged that Kmart stores did not report discounted prescription drug prices to Medicare Part D, Medicaid, and TRICARE, thereby receiving larger reimbursements than it was entitled to.

Kmart Wrongdoing Exposed by Whistleblower

In 2008, pharmacist James Garbe filed a qui tam suit under the FCA against Kmart. He alleged that Kmart pharmacies offered discounted generic drug prices to customers who paid cash through various programs, yet knowingly failed to disclose those prices to federal health programs. Instead, between 2004 and 2016, it reported to Medicare, Medicaid, and TRICARE its customary prices for drugs, which were then used to establish reimbursement rates. The incorrect claims lead to Kmart receiving higher reimbursements than the business was entitled to.